BRAND NAME INGREDIENTS DOSAGE FORM STRENGTH
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BRAND NAME INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES Amiloride/Hydrochlorothiazide Amiloride/Hydrochlorothiazide Tab 5MG/50MG Y N ADD to PDL with QL = 1/day BD Insulin Syringe Ultrafine/U100/1ML/31G X 15/64" Naphazoline; Pheniramine Ophthalmic BD Insulin Syringe Ultrafine/U100/1ML/31G X 15/64" Misc NA N Y ADD to PDL Naphazoline; Pheniramine Soln B Y Phenylephrine-DM Syrup Phenylephrine-DM Syrup 2.5-5 MG/5ML Soln Y Y Potassium ChlorideE ER * Potassium Chloride ER * Cap 8 MEQ Y N Prezista Darunavir Tab 800 MG N N Protopic Tacrolimus Oint 0.03% Oint 0.03% N N Protopic Tacrolimus Oint 0.1% Oint 0.10% N N Bicalutamide Bicalutamide Tab 50MG Y N Elidel Pimecrolimus Cream 1% CR 1% N N Carafate Sucralfate Susp 1GM/10ML N N First omeprazole Omeprazole suspension compounding kit Susp 2MG/ml N N 0.027%; 0.315% 2.5-5 MG/5ML ADD to PDL with QL = 15/30 days ADD to PDL with a QL = 240 mL/dispense ADD to PDL with QL = 1/day ADD to PDL with a QL = 1/day Add to PDL with PA designation and with a QL = 30/30days and AL ≥ 2 years Add to PDL with PA designation and with a QL = 30/30days and AL ≥ 16 years Add QL = 1/day across all Plans Add QL = 30/30 across all Plans and AL ≥ 2 years (PA designation remains in place) Add to PDL with AL = < 6 years & QL = 420mls/dispense Add to PDL with QL = 300 ● BRAND NAME INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES Acetaminophen Soln 100 MG/ML Acetaminophen Soln 100 MG/ML Soln 100MG/mL Y Y Delzicol Mesalamine Cap DR 400 MG CPDR 400MG N N Irbesartan Tab Irbesartan Tab Tab 150MG Y N Irbesartan Tab Irbesartan Tab Tab 300MG Y N Irbesartan Tab Irbesartan Tab Tab 75MG Y N Irbesartan-Hydrochlorothiazide Irbesartan-Hydrochlorothiazide Tab Y N Irbesartan-Hydrochlorothiazide Irbesartan-Hydrochlorothiazide Tab Y N Phenylephrine-DM Soln Phenylephrine-DM Soln Soln Y Y Theophylline solution Theophylline solution Soln 80MG/15mL Y N Intelence Etravirine Tab 25MG N N Viread Tenofovir Disoproxil Fumarate Tab 150MG N N Viread Tenofovir Disoproxil Fumarate Tab 200MG N N Viread Tenofovir Disoproxil Fumarate Tab 250MG N N Viread Tenofovir Disoproxil Fumarate Powd 40MG/GM N N Zerit Stavudine Soln 1MG/ML N N dexamethasone sodium phosphate dexamethasone sodium phosphate Inj 4mg/ML Y N Combivent Respimat albuterol/ipratropium Aero 100mcg/ 20mcg N N Escitalopram Escitalopram Oxalate Tab 5MG Y N Escitalopram Escitalopram Oxalate Tab 10MG Y N Escitalopram Escitalopram Oxalate Tab 20MG Y N Estradiol & Norethindrone Acetate Estradiol & Norethindrone Acetate Tab 0.5MG; 0.1MG Y N Trospium Chloride Trospium Chloride Tab 20MG Y N Dextromethorphan HBr Liquid 7.5 mg/5ml Y N Guaifenesin Liquid 100 mg/5ml Y N 150MG/12.5 MG 300MG/12.5 MG 2.5-5 MG/5ML Add to PDL with QL = 30 Add to PDL with QL = 6/day Add to PDL with QL = 1/day Add to PDL with QL = 1/day Add to PDL with QL = 1/day Add to PDL with QL = 1/day Add to PDL with QL = 1/day Add to PDL with QL = 240mL Add to PDL with QL = 475/dispense Add to PDL with QL = 4/day Add to PDL with QL = 1/day Add to PDL with QL = 1/day Add to PDL with QL = 1/day Add to PDL with QL = 240/30 days Add to PDL with QL = 80/day Add to PDL with QL = 1 dispense/month Add to PDL with QL= 4/30 Add to PDL with QL= 1/day Add to PDL with QL= 1/day Add to PDL with QL= 1/day Add to PDL with QL= 1/day Add to PDL with QL = 2/day - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days ● INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES Guaifenesin Syrup 100mg/5ml Y Y Chlorpheniramine & Phenylephrine Liquid 1-2 MG/ML Y Y Pseudoephedrine-DM Liquid 15-7.5 MG/5ML Y N DEXATREX D Pseudoephedrine-DM Elixir 20-10 MG/5ML N N EQL INFANT Pseudoephedrine-DM Solution 7.5-2.5 MG/0.8ML N N Chlorpheniramine-DM Liquid 2-15 MG/5ML Y N Chlorpheniramine-DM Syrup 1-7.5 MG/5ML N Y Promethazine-DM Syrup 6.25-15 MG/5ML Y N Pseudoephed-Chlorphen-DM Liquid 15-1-5 MG/5ML Y N Pseudoephed-Chlorphen-DM Liquid 15-1-7.5 MG/5ML Y N Pseudoephed-Bromphen-DM Elixir 15-1-5 MG/5ML Y N Pseudoephedrine-Guaifenesin Syrup 30-100 MG/5ML Y N Dextromethorphan-Guaifenesin Liquid 5-100 MG/5ML Y Y Dextromethorphan-Guaifenesin Liquid 10-200 MG/5ML Y Y BIOSPEC DMX, TRISPEC DMX Dextromethorphan-Guaifenesin Liquid 15-25 MG/5ML N N SCOT-TUSSIN Dextromethorphan-Guaifenesin Liquid 15-200 MG/5ML N N Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML Y Y BRAND NAME DIMETAPP - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=30/6 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Limited to Ages 2 and Older; Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days ● BRAND NAME INGREDIENTS 15-100 MG/5ML Y Y Pseudoephedrine w/ COD-GG Solution 30-10-100 MG/5ML Y N Pseudoephedrine w/ DM-GG Liquid 30-10-100 MG/5ML Y N N N N N N N N N N N ELMIRON SOMNOTE Chloral Hydrate SYMBICORT DULERA DULERA *Ferrous Fumarate-FA-B Complex-C-Zn-Mg-Mn-Cu *White Petrolatum-Mineral Oil Ophth Hydrocortisone INSULIN SYRG INS SYRINGE, INSULIN SYRG INSULIN SYRG INS SYRINGE, INSULIN SYRG INSULIN SYRG INSULIN SYRG INSULIN SYRG INSULIN SYRG INSULIN SYRG INSULIN SYRG INSULIN SYRG INSULIN SYRG GENERIC OTC NOTES Dextromethorphan-Guaifenesin Syrup Budesonide-Formoterol Fumarate Dihyd Budesonide-Formoterol Fumarate Dihyd Mometasone FuroateFormoterol Fumarate Mometasone FuroateFormoterol Fumarate Pentosan Polysulfate Sodium SYMBICORT DOSAGE STRENGTH FORM Insulin Syringe/Needle U-100 1/2 ML 29 x 5/16" Insulin Syringe/Needle U-100 1/2 ML 29 x 1/2" Insulin Syringe/Needle U-100 1/2 ML 30 x 5/16" Insulin Syringe/Needle U-100 1/2 ML 30 x 1/2" Insulin Syringe/Needle U-100 1 ML 25 x 5/8" Insulin Syringe/Needle U-100 1 ML 25 x 1" Insulin Syringe/Needle U-100 1 ML 26 x 1/2" Insulin Syringe/Needle U-100 1 ML 27 x 1/2" Insulin Syringe/Needle U-100 1 ML 27 x 5/8" Insulin Syringe/Needle U-100 1 ML 28 x 5/16" Insulin Syringe/Needle U-100 1 ML 28 x 1/2" Insulin Syringe/Needle U-100 1 ML 29 x 7/16" Capsule 80-4.5 MCG/ACT 160-4.5 MCG/ACT Aerosol 100-5 MCG/ACT Aerosol 200-5 MCG/ACT 100 MG Capsule 500 MG N N Tablet 106-1 MG*** Y Y Ophth Oint Y N Y Y Aerosol Aerosol Aerosol Aerosol Cream 1% - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Max Qty=240/claim; Max Fills=1/30 days - Daily Dosage=3 - Max Qty=45/25 days - Daily Dosage=1 - Package Limit=1/claim - Retail only: Package Limit=1/claim Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 ● BRAND NAME INGREDIENTS Insulin Syringe/Needle U-100 1 ML 29 x 1/2" Insulin Syringe/Needle U-100 1 INSULIN SYRG ML 29 x 5/16" Insulin Syringe/Needle U-100 1 INSULIN SYRG ML 30 x 5/16" Insulin Syringe/Needle U-100 1 INSULIN SYRG ML 30 x 7/16" Insulin Syringe/Needle U-100 1 INS SYRINGE, INSULIN SYRG ML 30 x 1/2" Insulin Syringe/Needle U-100 1 INSULIN SYRG ML 31 x 5/16" Insulin Syringe/Needle U-100 INSULIN SYRG 0.3 ML 31 x 5/16" Insulin Syringe/Needle U-100 2 INSULIN SYRG ML 27.5 x 5/8" Insulin Syringe/Needle U-100 2 INSULIN SYRG ML 29 x 1/2" Insulin Syringe/Needle U-100 INSULIN SYRG 0.3 ML 29 x 7/16" Insulin Syringe/Needle U-100 INSULIN SYRG 0.3 ML 29 x 1" Insulin Pen Needle 29 G X 8 MM AUTOSHIELD (5/16") 1ST TIER UNI, AUTOSHIELD, EASY Insulin Pen Needle 29 G X 12 TOUCH, INCONTROL, INSULIN PEN... MM BD PEN NEEDL, LITETOUCH, PEN Insulin Pen Needle 29 G X 12.7 NEEDLE, SURE COMFORT, SUREMM FINE INSUPEN ULTR, NOVOFINE, NOVOFINE AUT, NOVOTWIST, PEN Insulin Pen Needle 30 G X 8 MM NEEDLES 1ST TIER UNI, BD PEN NEEDL, COMFORT EZ, EASY COMFORT, Insulin Pen Needle 31 G X 5 MM EASY TOUCH... 1ST TIER UNI, CLICKFINE, COMFORT Insulin Pen Needle 31 G X 6 MM EZ, EASY TOUCH, IN CONTROL... 1ST TIER UNI, BD PEN NEEDL, CLICKFINE, COMFORT EZ, EASY Insulin Pen Needle 31 G X 8 MM COMFORT... 1ST TIER UNI, BD PEN NEEDL, Insulin Pen Needle 32 G X 4 MM CLICKFINE, INSUPEN, PEN (5/32") NEEDLES... Insulin Pen Needle 32 G X 5 MM EASY TOUCH, NOVOTWIST (1/5") EASY TOUCH, INSUPEN SENS, Insulin Pen Needle 32 G X 6 MM NOVOFINE (1/4") ACE AERO CLD, ACTIVITY PCH, *Respiratory Therapy Supplies ADULT MASK, AEROSOL MASK, Misc** AEROTRC PLUS... INS SYRINGE, INSULIN SYRG DOSAGE STRENGTH FORM GENERIC OTC NOTES Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Daily Dosage=5 Y - Max Qty=1/360 days ● BRAND NAME INGREDIENTS AERCHMBR PLS, AERCHMBR Z-, AEROCHAMBER, ARIAL, BREATHERITE... *Spacer/Aerosol-Holding Chambers - Device*** INSPIREASE INSPIREASE ACCU-CHEK, ACCU-CHEK IN, ACCUTREND, ADVANCE, ADVANCE NORM... ACURA CONTRL, ADVOCATE, ADVOCATE+, AGAMATRIX, BAYER BREEZE... ACURA CONTRL, ADVANCE, AGAMATRIX, ASCENSIA, ASSURE DOSE... ACURA CONTRL, ADVOCATE, ADVOCATE+, BAYER BREEZE, BAYER CONTOR... A1C NOW, ACCU-CHEK, ACURA BLOOD, ACURA PLUS, ADVANCE... 1ST CHOICE, ACCU-CHEK, ACTILANCE, ADV TRAVEL, ADVOCATE... ADJ LANCING, ADV LANCING, ADVOCATE, ALTRNATE SIT, AQUA LANCE... AMD FOAM, CUREX SPONGE, CURITY AMD, CURITY GAUZE, CURITY SPONG... CURITY COVER, CURITY GAUZE, CURITY SPONG, CURITY STRIP, DERMACEA... ADH DRESSING, ALL PURPOSE, AMD FOAM, BIATAIN, BIATAIN FOAM... AIMSCO, ATLAS CONDOM, CAUT CONDOMS, CLASS ACT, COLOR CONDOM... ATLAS CONDOM, KIMONO MICRO, MENTOR, TROJAN, TROJAN PLUS... ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO COIL ORTHO COIL *Spacer/Aerosol-Holding Chamber Supplies - Bags*** *Spacer/Aerosol-Holding Chamber Supplies Mouthpieces*** *Blood Glucose Calibration Liquid*** DOSAGE STRENGTH FORM GENERIC OTC NOTES Y - Max Qty=2/360 days Y - Max Qty=3/180 days Y - Max Qty=1/180 days N - Max Qty=1/90 days *Blood Glucose Calibration Liquid - High*** - Max Qty=1/90 days *Blood Glucose Calibration Liquid - Normal*** - Max Qty=1/90 days *Blood Glucose Calibration Liquid - Low*** - Max Qty=1/90 days - PA, NDC 56151124001 TRUERESULT KIT; PA, NDC 56151088880 TRUETRACK KIT SYSTEM - Max Qty=200/30 days *Blood Glucose Monitoring Kit w/ Device**** Y *Lancets**** Y *Lancet Devices**** Y *Gauze Pads & Dressings - Pads 2" X 2"*** Y *Gauze Pads & Dressings - Pads 3" X 3"*** Y *Gauze Pads & Dressings - Pads 4" X 4"*** Y Condoms Latex Lubricated Y - Max Qty=36/claim Condoms Latex Non-Lubricated Y - Max Qty=36/claim Diaphragm Arc-Spring 65 MM Diaphragm Arc-Spring 70 MM Diaphragm Arc-Spring 75 MM Diaphragm Arc-Spring 80 MM Diaphragm Coil Spring Kit 50 MM Diaphragm Coil Spring Kit 100 MM N N N N N N - Max Qty=1/180 days - Max Qty=1/365 days - Max Qty=1/180 days ● BRAND NAME ORTHO COIL ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES Diaphragm Coil Spring Kit 105 MM Diaphragm Flat Spring Kit 55 MM Diaphragm Flat Spring Kit 60 MM Diaphragm Flat Spring Kit 65 MM Diaphragm Flat Spring Kit 70 MM Diaphragm Flat Spring Kit 75 MM Diaphragm Flat Spring Kit 80 MM Diaphragm Flat Spring Kit 85 MM Diaphragm Flat Spring Kit 90 MM Diaphragm Flat Spring Kit 95 MM N N N N N N N N N N ALCOH-GLOVE, ALCOHOL, ALCOHOL PREP, ALCOHOL SWAB, BD SWAB *Alcohol Swabs*** BFLY... LAN-O-SOOTHE, LANOLIN HYDR, LANSINOH CUPRIMINE SANDIMMUNE CELLCEPT MYFORTIC MYFORTIC RAPAMUNE RAPAMUNE RAPAMUNE RAPAMUNE Y Capsule Capsule Capsule Solution Capsule Capsule Capsule Solution Capsule Tablet Suspensi Mycophenolate Mofetil For Oral on Mycophenolate Sodium (Mycophenolic Acid Equiv) Tab Tablet DR DR Mycophenolate Sodium Tablet DR (Mycophenolic Acid Sirolimus Tablet Sirolimus Tablet Sirolimus Tablet Sirolimus Oral Solution Tacrolimus Capsule Tacrolimus Capsule - Max Qty=400/claim - PA, NDC 49452084401 LANOLIN OIN; PA, NDC 49452394002 LANOLIN OIN Lanolin Penicillamine Cyclosporine Cyclosporine Cyclosporine Oral Cyclosporine Modified Cyclosporine Modified Cyclosporine Modified Cyclosporine Modified Oral Mycophenolate Mofetil Mycophenolate Mofetil - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days - Max Qty=1/180 days 250 MG 25 MG 100 MG 100 MG/ML 25 MG 50 MG 100 MG 100 MG/ML 250 MG 500 MG N Y Y N Y Y Y Y Y Y N N N N N N N N N N - Daily Dosage=4 - Daily Dosage=4 - Daily Dosage=8 - Daily Dosage=4 - Daily Dosage=4 - Daily Dosage=4 - Daily Dosage=8 - Daily Dosage=2 - Daily Dosage=4 200 MG/ML N N - Daily Dosage=15 180 MG N N - Daily Dosage=2 360 MG N N - Daily Dosage=4 0.5 MG 1 MG 2 MG 1 MG/ML 0.5 MG 1 MG N N N N Y Y N N N N N N - Daily Dosage=6 - Daily Dosage=2 - Daily Dosage=4 - Daily Dosage=3 - Daily Dosage=3 ● BRAND NAME INGREDIENTS AZASAN AZASAN Tacrolimus Azathioprine Azathioprine Azathioprine Sodium Polystyrene Sulfonate Oral DOSAGE FORM Capsule Tablet Tablet Tablet Suspensi on *Sodium Polystyrene Sulfonate Powder Erythromycin Ethylsuccinate Azithromycin Bupropion HCl (Smoking Deterrent) Tablet Tablet E.E.S. 400, ERYTHROM ETH Nicotine TD Nicotine TD Nicotine TD ZOMIG ZOMIG Nicotine Polacrilex Nicotine Polacrilex Nicotine Polacrilex Nicotine Polacrilex Dihydroergotamine Mesylate Dihydroergotamine Mesylate Nasal Almotriptan Malate Almotriptan Malate Eletriptan Hydrobromide (Base Equivalent) Eletriptan Hydrobromide (Base Equivalent) Zolmitriptan Zolmitriptan ZOMIG Zolmitriptan Nasal MIGRANAL AXERT AXERT RELPAX RELPAX ZOMIG ZMT ZOMIG ZMT CAFERGOT Vitamin D3 Vitamin D3 Fluoxetine Mag Oxide Fexofenadine Zolmitriptan Orally Disintegrating Zolmitriptan Orally Disintegrating Acetaminophen-IsomethepteneDichloral Ergotamine w/ Caffeine cholecalciferol Cholecalciferol Fluoxetine Magnesium Oxide Fexofenadine STRENGTH GENERIC OTC NOTES 5 MG 50 MG 75 MG 100 MG Y Y N N N N N N 15 GM/60ML Y N Y N - Max Qty=454/claim 400 MG 250 MG N Y N N - Max Qty=6/claim Tablet SR 150 MG Y N 7 MG/24HR Y Y 14 MG/24HR Y Y 21 MG/24HR Y Y 2 MG 4 MG 2 MG 4 MG 1 MG/ML Y Y Y Y Y Y Y Y Y N Spray 4 MG/ML N N Tablet tablet 6.25 MG 12.5 MG N N N N Tablet 20 MG N N Tablet 40 MG N N Tablet Tablet 2.5 MG 5 MG 5 MG/Spray Unit N N N N N N Tablet 2.5 MG N N Tablet 5 MG N N Y N N Y Y Y Y Y N Y N N N Y Patch 24 HR Patch 24 HR Patch 24 HR Gum Gum Lozenge Lozenge Injection Spray Capsule Tablet Cap Cap Cap Tab ALL 325-65-100 MG 1-100 MG 5,000 u 50,000 U 40 mg 400 mg ALL - Daily Dosage=3 - Daily Dosage=3 - Daily Dosage=3 QL = 2/day QL = 8/30 days ● BRAND NAME INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES N N Change QL from 4/day to 6/day N N Recommend PKG Limit = 1 btl/claim 0.04% Y Y CR 0.08% Y Y Capsaicin Gel 0.025% Gel 0.03% Y Y Capsaicin Gel 0.05% Capsaicin Gel 0.05% Gel 0% Y Y Capsaicin Gel 0.075% Capsaicin Gel 0.075% Gel 0% Y Y Capsaicin Lotion 0.035% Capsaicin Lotion 0.035% Lotn 0% Y Y Montelukast Sodium Tab Montelukast Sodium Tab Tab 10MG Y N Montelukast Sodium Chew Tab Montelukast Sodium Chew Tab Tab 4MG Y N Montelukast Sodium Chew Tab Montelukast Sodium Chew Tab Tab 5MG Y N Simply Thick Xanthan Gum Gel NA Y N Plan B, Next Choice, My Way Levonorgestrel Tab 1.5 MG Tab 1.5MG N Y Plan B etc. Levonorgestrel Tab 0.75 MG Tab 0.75MG N Y Quetiapine Fumarate Tab 25 MG Tab 25MG Y N Quetiapine Fumarate Tab 50 MG Tab 50MG Y N Quetiapine Fumarate Tab 100 MG Tab 100MG Y N Quetiapine Fumarate Tab 200 MG Tab 200MG Y N Quetiapine Fumarate Tab 300 MG Tab 300MG Y N Quetiapine Fumarate Tab 400 MG Tab 400MG Y N Olanzapine Tab 2.5 MG Tab 2.5MG Y N Olanzapine Tab 5 MG Tab 5MG Y N Olanzapine Tab 7.5 MG Tab 7.5MG Y N Kaletra Lopinavir; Ritonavir Tab Kaletra Lopinavir-Ritonavir Soln Capsaicin Cream 0.035% Capsaicin Cream 0.035% CR Capsaicin Cream 0.075% Capsaicin Cream 0.075% Capsaicin Gel 0.025% 200MG; 50MG 400100mg/5ml (80-20 mg/ml) Add QL = 1 package/dispense Add QL = 1 package/dispense Add QL = 1 package/dispense Add QL = 1 package/dispense Add QL = 1 package/dispense Add QL = 1 package/dispense Remove Step therapy edit Remove Step therapy edit Remove Step therapy edit Add AL > 1 year of age Change QL to 1 tablet per dispense per 21 days up to a maximum of 4 fills per year AND remove the age limit Remove age limits Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming ● DOSAGE STRENGTH FORM GENERIC OTC NOTES Olanzapine Tab 10 MG Tab 10MG Y N Olanzapine Tab 15 MG Tab 15MG Y N Olanzapine Tab 20 MG Tab 20MG Y N Ziprasidone HCl Cap 20 MG Cap 20MG Y N Ziprasidone HCl Cap 40 MG Cap 40MG Y N Ziprasidone HCl Cap 60 MG Cap 60MG Y N Ziprasidone HCl Cap 80 MG Cap 80MG Y N BRAND NAME INGREDIENTS Abilify Aripiprazole Tab 2 MG Tab 2MG N N Abilify Aripiprazole Tab 5 MG Tab 5MG N N Abilify Aripiprazole Tab 10 MG Tab 10MG N N Abilify Aripiprazole Tab 15 MG Tab 15MG N N Abilify Aripiprazole Tab 20 MG Tab 20MG N N Abilify Aripiprazole Tab 30 MG Tab 30MG N N Abilify Aripiprazole Oral Solution 1 MG/ML Soln 1 MG/ML N N Abilify ODT Aripiprazole Orally Disintegrating Tab 10 MG ODT 10MG N N Abilify ODT Aripiprazole Orally Disintegrating Tab 15 MG ODT 15MG N N Cefprozil Susp 125 MG/5ML Y N Clindamycin Palmitate HCl Soln 75 MG/5ML (Base Equiv) N Y Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Remove ST programming. Apply PA criteria guidelines. Pkg Size- 100ml, 50ml and 75ml btl. Recommend a limit of 1 btl/claim supports max dose. PKG Size= 100ml Btl, Recommend Pkg limit= 1 bottle/claim ● BRAND NAME INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES SAXAGLIPTIN HYDROCHLORIDE ONGLYZA Tab 2.5MG N N SAXAGLIPTIN HYDROCHLORIDE ONGLYZA Tab 5MG N N Cetirizine HCl Syrup 5 MG/5ML Y Y Polyethylene Glycol Oral Powder 3350 Y N TITR PAK 12.5 MG, 25 N MG & 50 MG N Sulfacetamide Sodium w/ Sulfur Susp 10-5% N N Bacitracin Oint 500 U/GM Y Y Milnacipran Savella Acyclovir ZOVIRAX Oint 5% N N Fluorouracil CARAC Cream 0.50% N N Fexofenadine Fexofenadine ALL ALL Y Y Cream 0.25% Y N Desoximetasone Recommend Daily Dose=1 Recommend Daily Dose=1 PKG Size= 118ml Btl, Recommend Pkg Size= 1 bottle/claim 17gm/day is the recommended dosage. Pkg size= 14 oz (255gm); 26 oz (527gm); 1 Carton= 14 pkt of 17gm/ea. Recommend Pkg Size= 1 Btl or Carton/30 days 1 TITR PAK per 365 days Pkg Size= 1 Tube or Bottle, Recommend Pkg Size= 1/claim Recommend Pkg Limt= 1 tube/claim Pkg size= 15gm, 30gm tube. Recommend Pkg Limit= 1 tube/claim Pkg size= 40gm, Recommend Pkg Limit=1 tube/claim Delete Step Therapy Criteria Pkg size= 15gm, 100gm, Recommend Pkg Limit= 1 tube /claim ● BRAND NAME INGREDIENTS DOSAGE STRENGTH FORM GENERIC OTC NOTES Mebendazole Mebendazole Tab 100MG Y N TB24 200MG N N TB24 300MG N N TB24 400MG N N Seroquel XR Seroquel XR Seroquel XR Quetiapine Fumarate Tab SR 24HR Quetiapine Fumarate Tab SR 24HR Quetiapine Fumarate Tab SR 24HR Rimantadine Hydrochloride Rimantadine Hydrochloride Tab 100MG Y N Prevacid Solutabs lansoprazole Tab 15MG N N Prevacid Solutabs lansoprazole Tab 3f0MG N N Ketoconazole Ketoconazole Tab 200MG Y N Remove from PDL. No longer available in market place REMOVE FROM PDL. Apply COC. REMOVE FROM PDL. Apply COC. REMOVE FROM PDL. Apply COC. Remove from PDL. No COC applies Remove from PDL. No COC applies. Apply POS messaging: Use First omeprazole Remove from PDL. No COC applies. Apply POS messaging: Use First omeprazole Remove from PDL due to safety warning
